Joshua Freeman, MD University of Kansas SOM STFM MSE Conference, Houston, Jan 2011

 John Rawls, A Theory of Justice and others  “All social primary goods – liberty and opportunity, income and wealth, and the bases of self-respect – are to be distributed equally unless an unequal distribution of any or all of these goods is to the advantage of the least favored.” Rawls, “A Theory of Justice”, Belknap Press Cambridge, MA 1971, p 303

 "The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough to those who have too little" -- Franklin Roosevelt

 Do we have a system of social justice as Rawls or Roosevelt describe in the US?  NO.  We have a system in which the most privileged exert great influence, and (mostly seem to) use it to increase their privilege.

 Article 25: Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. 

 “... health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right...”

 Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination

 “The physicians are the natural advocates* of the poor, and social problems fall to a large extent within their jurisdiction.”  *sometimes translated as “attorneys”  Rudolf Virchow, “ Report on the Typhus Epidemic in Upper Silesia”

 Paul Farmer: Pathologies of Power; Partner to the Poor: a Paul Farmer reader  Social Medicine, journal published by the Department of Family and Social Medicine at Montefiore Medical Center/Albert Einstein COM 

 Cares for the health of people in the context of their families and communities  NOT primarily hospital based, but ambulatory and community based  Identifies health needs of people – prevention and treatment

 Before WW II: General Practitioners One year of internship Incomplete residencies (esp surgery)  1940s-60s Growth of Specialists  Loss of many GPs to retirement and death; many towns lost all doctors

 1966: Willard Report Millis Report Folsom Report  “The American people want a personal physician”  Now: >80,000 FPs / GPs

 A generalist specialty Others: Gen Peds, Gen Int Med  Prevention and treatment  All places where care is given  “A good FP would be one who would provide a strong professional relationship in which I could approach him/her with any problem and get help solving it.” – H. Jason

 A specialty based on the relationship with the PATIENT, not the patient’s Disease Age Gender, etc.

 Ecology =The study of the relationship between organisms and their environment  Medical ecology = the relation between people and the environment(s) in which they receive medical care.

New types of insurance New professionals: NPs, PAs New technologies! Family physicians instead of general practitioners Managed care How has the medical ecology changed in the year 2000?

1000 people 800 have symptoms 327 consider seeking medical care 217 visit a physician’s office 113 visit primary care physician’s office 65 visit CAM provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency department 8 are in a hospital <1 is in an academic health center hospital New Ecology of Medical Care

 Continuity  (First) Contact  Community  Comprehensiveness

 Context  Compassion  Collaboration  Commitment

 Family Medicine training is ambulatory and in the community  Family Medicine is broad-based, caring for people, not diseases or body parts  Family Medicine integrates knowledge of relationships within the family (and community) to apply it to the health of the person

 Rural, urban  Not tied to high-tech equipment, teaching hospitals  Able to meet most needs for most people  “High touch”

 Complex multi-system chronic disease  Acute disease  Prevention  Social and psychological and relationship issues  Family Physicians ask for trouble

 “Family and Social Medicine”  “Family and Community Medicine”  “Family and Preventive Medicine”  Even preventive medicine and public health are often subspecialized  Family medicine is generalist

 Implements health priorities in the community and with the individual  Even public health is subspecialized; practitioners and researchers work on Air pollution Seat belts Obesity Smoking Violence Etc.

 The family physician must talk to her patients about obesity…  But also about smoking.  She must encourage the use of seat belts  But also bicycle helmets  She must be concerned about lead poisoning  But also about domestic violence.

 Community is important context of both Medicine as Social Justice and Family Medicine  Health cannot be created in the hospital, or even in the office  Health of the population requires work in the community  Healthy communities require healthy lives, not just medicine

 Of course. Primary care specialties: General pediatrics General internal medicine  If the training is appropriate.  If the training is people-centered, rather than disease centered  Need a toolbox, not just a hammer, as every problem is not a nail.

 Is not all hospital based  Has major community outreach  Integrates prevention and “asking for trouble” as a core value  Offers rural, inner-city, international experiences  Will train you to practice “anywhere”  Has great role models

 Contact information: Joshua Freeman, MD Department of Family Medicine, KUMC 3901 Rainbow Blvd., MS 4010 Kansas City, KS